Provider Demographics
NPI:1104036458
Name:SMITH, MARK H (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:SMITH
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2751 ALBERT L BICKNELL DR
Mailing Address - Street 2:SUITE 3D
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3920
Mailing Address - Country:US
Mailing Address - Phone:318-212-4799
Mailing Address - Fax:318-424-3642
Practice Address - Street 1:2751 ALBERT L BICKNELL DR
Practice Address - Street 2:SUITE 3D
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3920
Practice Address - Country:US
Practice Address - Phone:318-212-4799
Practice Address - Fax:318-424-3642
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2013-07-15
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Provider Licenses
StateLicense IDTaxonomies
LA201297208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA21489Medicaid